Special Enrollment Rules §6504

to get – enroll – sign up for Health Insurance when it’s NOT Open Enrollment

IMHO The simple way to review the Special Enrollment Rules – is the
plain English  Insurance Company brochures below, rather than reviewing the actual legal code

#ARPA American Rescue Plan Act

Enrollment from April 12th through 12.31.2021

FAQ’s for Brokers  4.22.2021  

While you are allowed to enroll on the last day of the monthDO NOT EVEN THINK ABOUT getting your ID Cards on the first Monday of the next month.   If you enroll past the 15th of the month, we’ve been forced to have you sign an acknowledgement that you understand you won’t have all the paperwork on the 1st of the month, even though you have coverage and premiums are due. 

See our COVID ARPA page on uninsured and those who qualify for more subsidies.

Unemployment Enhancements Silver 94 

Get instant quote & subsidy calculation

February through May 15th Special Enrollments

Get FREE #Instant Individual & Family  California  Quotes - Including Tax Subsidy Calculation - Guaranteed Issue - No Pre-X Claus

Get FREE Instant Quotes - Including Tax Subsidy Calculation - Guaranteed Issue - No Pre-X Clause

Full Instructions to use Individual Quote Engine
Takes all the complexity out of CFR §1.36B-3 *

how to get quote - full instructions video by steve

 

Blue Shield  
Plain English, Effective Dates & Proof Required for Special Enrollment

Blue Shield Logo - get speical enrollment rules

 

Health Net Rules, from their Paper Application 

Verification of Special Enrollment

Consumers and brokers completing an online application will be notified in the application that Covered California may seek to verify the validity of their self-attested Qualifying Life Event (QLE) in order to be eligible for Special Enrollment.

Covered California will contact a random sample of consumers who enrolled during a Special Enrollment Period (SEP) to request proof of the QLE. If the consumer does not provide acceptable documentation of their QLE within 30 days of the date on the original notice, their coverage can be terminated.

If a consumer is found to have been fraudulently enrolled in a Covered California health insurance plan without a Qualifying Life Event, the broker who assisted the consumer could potentially lose their certification.  Brokers don’t risk losing your certification with Covered California and ensure all consumers who attest to having experienced a QLE are able to provide proof that they qualify for special enrollment. February 10, 2021 Bulletin *

Covered CA Certified Agent

#Covered CA Certified Agent  

No extra charge for complementary assistance 

Videos on how great agents are

I'm in Charles VIDEO

I'm in Charles

I'm in Sonia VIDEO

I'm in Sonia

 

FLASH

President Biden is signing an order to have a Special Open Enrollment from February 15th to May 15th!  The Hill * KFF.org *   Covered CA is calling it Special Enrollment.  Some Insurance Companies are allowing anyone to enroll, calling it Open Enrollment.  Get a quote, email us [email protected]  and we will check & verify for you.

 

#Open Enrollment in California starts 11.1 and ends 1.31  AB 1309  *  CA Insurance Code 10965.3 *

NEWS FLASH – Open Enrollment extended to December 30th for a January start date.  Covered CA.com *

Please note that Medi-Cal enrollment is year round.

CA Healthline Open Enrollment – What you need to know


Health Net Webinar

HN graphic of open enrollment dates

HN Email dated 10.8.2020


Molina Webinar

Sutter’s Underwriting Guide for 2021

SEP Special Enrollment Period Consumers Auto-Renewing for 2021

The renewal period [as opposed to brand new coverage] for 2021 coverage begins October 1.

After October 1, if you have NEW consumers purchasing coverage for the remainder of 2020 after experiencing a Qualifying Life Event (QLE) that triggers a Special Enrollment Period (SEP), and those consumers want to have 2021 coverage also, do not actively enroll them in 2021 coverage.

CalHEERS will process auto-renewals of existing 2020 enrollments, and actively purchasing 2021 coverage for a new enrollee who has purchased any portion of 2020 coverage after October 1 may create a duplicate enrollment or renewal fallout.

We will work on getting the above in plain English.  See button above or below for FAQ’s or email us  [email protected]

 

Enrollments after the 14th of the month must acknowledge in writing that they understand they might not have their ID cards by the effective date.   Please don’t wait till the last minute!

Please note that CA now has an individual mandate penalty!  $695 per adult and $347.50 per child or  2.5 percent of your gross income that is above the filing threshold based on your tax filing status and number of dependents.

Subsidy eligibility for  APTC has increased from 400 to 600% of FPL Federal Poverty Level.

If you need coverage NOW and it’s not Open Enrollment –

Please review all the Qualifying Events
§6504 CA CCR’s for Special Enrollment and let’s see if you are eligible

Appoint us as your Covered CA Agent – NO CHARGE!

 

AB 1309

California Insurance Code  § 10965.4  or 10965 – 10965.18

 

#CCR.10  California  Code of Regulations
§6504 Special Enrollment Periods

FYI Federal  §155.420   Special enrollment periods.

 

It seems that this section where I had cut & pasted the actual law and added comments and links, is just too much to read.  If you need the law… see the links above.  April 2021, I’m cutting out the law and just have the Covered CA interpretations.   One can only check on Government so much…

 

   Definitions  155.20]

lawfully present error, misrepresentation, misconduct, substantially violated a material provision of its contract in relation to the enrollee.

(7) An enrollee Definition, or his or her dependent enrolled in the same QHP – Qualified Health Plan, is determined newly eligible or ineligible for APTC (Subsidies) or has a change in eligibility for CSR. [Cost Sharing Reductions – Enhanced Silver]   RIGHT to change Silver Plans!

***View our webpage on change in eligibility due to income change

A change in income is not a Qualifying life event. If you select “other qualifying life event,” it puts a hold on the account.    In the future, for income changes you need to select “none of the above.”  Email dated 03/26/2018 11:57 AM from Covered CA

(d) § 155.420  The Exchange must allow a qualified individual or enrollee, and, when specified below, his or her dependent, to enroll in or change from one QHP to another if one of the following triggering events occur:

(4) The qualified individual’s or his or her dependent’s, enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, or agent of the Exchange or HHS, its instrumentalities, or a non-Exchange entity providing enrollment assistance or conducting enrollment activities. For purposes of this provision, misconduct includes the failure to comply with applicable standards under this part, part 156 of this subchapter, or other applicable Federal or State laws as determined by the Exchange.

 

Health & Safety Code 1399.849 (d)   
Virtually the same rules

 

Email clarification from Covered CA Broker Support

Hi Steve,

Basically the children lost subsidy eligibility because they actually qualify for Medi-Cal so they were removed from the policy. Unfortunately, even though this would seem to be an involuntary loss of coverage, it’s not considered a Qualifying Event because the children are not losing coverage; [minimum essential coverage] they are merely losing the private insurer coverage they preferred and instead getting state-sponsored Medi-Cal coverage. If later the children are denied Medi-Cal or lose eligibility for Medi-Cal, either situation would be a Qualifying Event. Email dated 9.12.2016 5:01 PM from a major insurance company manager

Adverse selection  a situation where an individual’s demand for insurance is positively correlated with the individual’s risk of loss.

#Permanent Move of your home – residence

gives you a Special Enrollment for Health Insurance

Just moved here?

CA Residency Guidelines #FTB1031  2019

Guidelines for determining residency

See our webpage on lawful presence & public charge

Residency for Medicare & Under 65 

  • A California resident is  one who is in California for other than a temporary or transitory purpose; or Domiciled in California, but outside California for a temporary or transitory purpose. (ftb.ca.gov). 
  • Amount of time you spend in California versus amount of time you spend outside California;
  • Location of your spouse and children;
  • Location of your principal residence;
  • Where your driver's license was issued;
  • Where your vehicles are registered;
  • Where you maintain your professional licenses;
  • Where you are registered to vote;
  • Location of the banks where you maintain accounts;
  • Location of your doctors, dentists, accountants, and attorneys;
  • Location of the church, temple or mosque, professional associations, or social and country clubs of which you are a member;
  • Location of your real property and investments;
  • Permanence of your work assignments in California; and
  • Location of your social ties.
  • In using these factors, it is the strength of your ties and closest connections not just the number of ties, that determines your residency (ftb.ca.gov/)

 

http://sanjivcpa.com to learn about various tax rules in California. Sanjiv Gupta CPA reviews rules related to residency in California.

Child, Related Pages
& Site Map 

Covered CA 2021 Individual Plans, Rates & #Information

Less than 1% premium increase

2021

  • The preliminary rate change for California’s individual market will be 0.6 percent in 2021, which marks a record low for the second consecutive year and follows California’s reforms to build on and strengthen the Affordable Care Act.
  • Covered California’s increased enrollment, driven by state policies and significant investments in marketing and outreach, has resulted in California having one of the healthiest individual market consumer pools and lower costs for consumers.
  • The impact of COVID-19 on health plans’ costs has been less than anticipated as many people deferred or avoided health care services in 2020, and while those costs are rebounding, it now appears the pandemic will have little effect on the total costs of care in California’s individual market for 2020 and 2021.
  • All 11 health insurance companies will return to the market for 2021, and two carriers will expand their coverage areas, giving virtually all Californians a choice of two carriers and 88 percent the ability to choose from three carriers or more. Covered CA Press Release * CA HealthLine *

Renewal Toolkit  Rev 10.2020 

IMHO it would be best to just wait till 11.1.2020.  That’s when we will have ALL the bulletins & materials for 2021.  Open Enrollment starts then, not this “crazy” thing with early renewals.

Insure Me Kevin.com 2021 analysis

 

29 comments on “Special Enrollment Periods Covered CA & Direct with Broker

  1. HealthCare.gov has extended their Special Enrollment Period to August 15, 2021.

    Last time, Covered California announced they would match, but this time they have been more vague so far.

    The fine print is also different between the two.

    • As I get the bulletins in from Covered CA, I’ll post them, under ARPA above.

      There is always the Supremacy Clause where States must meet or beat Federal Law.

      The core message of the Supremacy Clause is simple: the Constitution and federal laws (of the types listed in the first part of the Clause) take priority over any conflicting rules of state law. This principle is so familiar that we often take it for granted.

  2. 13 comments on “2021 Rates & Benefits – average 0.6% premium increase”

    1. Anonymous says:

      I opened my blue shield portal to pay my bill and lo and behold my rate more than doubled.

      What gives?

      You told me that by doing nothing my premium and plan would not change. I can understand a rate hike but this is ridiculous.

      Anything we can do at this late date?

      Reply
    2. Anonymous says:

      I want to get an Individual plan that UCLA accepts. I went to their webpage https://www.uclahealth.org/health-plans and they accept WAY MORE plans than just Blue Shield PPO and Oscar EPO!!! They also told me this over the phone.

      What’s the problem? Are you trying to sell me just the plans you make the most commission on?

      Reply
      • First off, we have to accept that Covered CA controls the CA marketplace, even if you get a plan directly from an insurance company. Check my website for the citation.

        Here’s the companies that write Individual Coverage in CA for 2020

        1. Anthem Blue Cross of California.
        2. Blue Shield of California.
        3. Chinese Community Health Plan.
        4. Health Net.
        5. Kaiser Permanente.
        6. L.A. Care Health Plan.
        7. Molina Healthcare.
        8. Oscar Health Plan of California.
        9. Sharp Health Plan.
        10. Valley Health Plan.
        11. Western Health Advantage.
        Source – Covered CA.com

        Go to this link https://individuals.healthreformquotes.com/companies/ and then scroll down for information on each company. You can get quotes here for 2020 on 11.1.2019 Sure you can get quotes from Covered CA or on each companies affliate link – no extra charge for our services, they pay us. It’s just that if you want us to help you compare, our tools won’t be ready till 11.1.2019.

        So, sure UCLA lists a lot of plans they accept, but how are you as an Individual going to buy them?

        Preferred Provider Organizations (PPOs)
        Aetna – Left CA!
        Anthem Blue Cross Left CA in 2018 but came back for 2020
        Blue Shield of California
        CIGNA – Left CA
        First Health
        Health Net of California OK, but not on the list for Individual Plans
        Interplan (a HealthSmart product)
        MultiPlan
        UFCM Health System, Inc. dba California Foundation Medical Care (CFMC)
        Prime Health Services
        Private Healthcare Systems (PHCS)
        TriCare Are you Military?
        UnitedHealthcare – Left CA for Individual Plans
        https://www.uclahealth.org/health-plans

        If you have Medicare we can help you on this website.

        If you have a business with at least one non-spousal employee, we can help you hereGroup Employer Quotes

        Reply
        • Anonymous says:

          What does Off Exchange mean?

          Reply
          • Exchange is a term for the entire United States. It means Health Care . gov or Covered CA, where you can get subsidies.

            Off Exchange, means that your not in Covered CA, but direct with an Insurance Company. Agent support at no additional charge!

            Pretty much, the rates and benefits in or out of Covered CA are exactly the same. Same crappy networks, etc.

            Due to a lawsuit to end subsidies for enhanced silver, direct is less $$$ if you want a silver plan and are not getting subsidies.

            Direct – some of the companies offer plans not available in Covered CA. BUT, they must meet Actuarial Value for the Metal Levels, have essential benefits, be guaranteed issue and no pre X!

            Reply
      • We do not care or want to comment about what anyone said over the phone. It’s just too unreliable. The courts won’t even accept hearsay evidence.

        Here’s where we spent an hour with our crystal ball, coming up with reasons why someone over the phone said something…

        It might often depend on the question you ask. You might not be asking the right question. Sure, UCLA accepts a lot of Insurance Companies. The question is, what companies can you buy as an individual that they accept?

        Reply
  3. 12 comments on “Open Enrollment & Special Enrollment”

    1. Anonymous says:

      We qualify for Medi-Cal based on our family income. We’ll just wait till November all the 2021 information is released to apply and it’s officially Open Enrollment.

      Reply
      • If your income is zero, there is Medi-Cal
        https://medi-cal.healthreformquotes.com/contact-info/

        Medi Cal enrollment is anytime you become “poor.” I don’t get compensated to help you with Medi-Cal. You can place your questions in the comments area on my Medi-Cal website, on the page most relevant. Your Social Worker gets paid to help you along with whatever Medi Cal HMO that you select.

        Assets are no longer an issue with Medi-Cal for health insurance and there is no estate recovery. Unless you go into a nursing home.

        Reply
        • It’s real easy to change your estimated income in our quote engine. If your income drops to Medi-Cal eligibility, then the subsidy will go away. Just put in the new estimate and click update.

          change subsidy amount

          Reply
      • See above for the Open Enrollment dates according to AB 1309 – the problem is, myself and one other agent are the only ones that read the law. Covered CA often makes up their own rules. We asked on June 17 and they said they didn’t know, but would send out a bulletin when they did.

        Reply
    2. Anonymous says:

      When is a good time to come by and sign up for open enrollment, for medical insurance?

      Reply
      • We suggest that you wait till after 11.1.2019 as our quote engine will be set to go, with rates, subsidies, comparisons and online enrollment.

        Covered CA has preliminary quoting now. I much prefer our own quote engine. We can show things in an easier to read fashion and your information is saved.

        Covered CA’s Shop & Compare tool is supposed to be ready 10.15.2019. One reason I don’t like it, is that it’s difficult to appoint an agent.

        We’ve sent you an appointment time.

        Website visitors can set a time for Face to Face, Skype, Facetime or phone by going to our scheduler https://steveshorr.com/intro/set-a-meeting/

        Reply
    3. Anonymous says:

      Does having a newborn affect my chances of getting individual health coverage during this AEP – Open Enrollment Period?

      Reply
  4. 4 comments on “Federal Qualifying Events, Triggers CFR §155.420 conical”

    1. Michele G says:

      my daughter is 23 years old and is a full time student. She has a small part time job but she needs insurance because she needs to go to the doctor.

      • When one needs Medical Services, is not a reason to be able to get Insurance. One purchases coverage beforehand to cover unexpected losses. This is the whole purpose of limited open enrollment periods, strict special enrollment times, avoidance of adverse selection, etc. Learn More

        In the time before ACA – Obamacare, there was medical underwriting and pre-existing condition clauses.

    2. Randy says:

      Hi Steve,

      1. I ran across your website while trying to educate myself on health insurance. My situation is a bit unique, so let me explain:

      2. I live in [redated] with my wife and 2 boys ([redated] years).

      3. I ended my COBRA in mid-March and need to pick up alternate insurance.

      4. Our Blue Cross coverage was great because I could use it in [redacted] (80% covered, I think).

      5. We return to California during Summers, and I am there for about 2 weeks per quarter otherwise.

      6. While we have about $[redacted] in assets, we currently have very little income.

      7. My wife is starting a company out here and I’m working part time, so our combined income is about $40k.

      8. I have 2 recurring medications (high blood pressure and high cholestrol) and I don’t mind paying out of pocket so long as I ride on some negotiated insurance price.

      9. Are you able to act as an insurance agent for me or can you recommend a policy?

      10 The Blue Shield Silver Plans (how I found you) seem to be about $600-$700 per month for the family, which is fine.

      Randy

      • 3 Since you lost COBRA – loss of minimum essential coverage, that gives you a Special Enrollment Period to purchase coverage, even though it’s not open enrollment.

        4 A PPO plan should be able to be used anywhere. The problem would be using out of network MD’s. That isn’t always 80%. Check the Specimen Evidence of Coverage, our Quote Engine and the brochures.

        Also check our International and Foreign Visitor Website for full information, enrollment and pricing.

        5 So, you have residency here and a California address we can use. See page 25 of the specimen policy as one must reside in the service area to get coverage.

        This could get confusing, as it’s not really defined what reside means. Here’s the closest definition I’ve found, from the CA Franchise Tax Board.

        You are not out of country long enough to qualify for an exemption from the Health Insurance Mandate.

        7 Is that MAGI income? See definition. It’s line 37 plus adding back in Foreign Income, Social Security and Tax Exempt Interest. If it is, then you may qualify for subsidies. Please use our FREE Quote Engine, which will not only show you Blue Shield PPO, but all the other plans as well, both in and out of Covered CA.

        8 This is the beauty of our quote engine. It will show the reimbursement levels for your Rx – Drugs. I guess you could do them mail order.

        9 Yes, I can be your agent. Please enter your information into our FREE Quote Engine, so that we can review your options and possible subsidy.

        10 I’m not sure if the $600/month is with subsidies or not. Please use our quote engine. We also need to verify MAGI income

  5. 6 comments on “Move – New County, State or Back in USA”

    1. Anonymous says:

      I’ve been out of the country since April 1 and plan to continue to be out of the country until at least Sept 1.

      My healthcare plan is $235.28 per month which seems both expensive and pointless while I’m out of the country since there are very little benefits abroad.

      Is it possible to get a retroactive refund on my healthcare for these months and cancel the policy until I’m back in the states?

      Reply
      • I doubt that your 6 month stay out of country changes anything with your residency.

        What does “intends to reside” mean?

        For the purposes of § 155.305(a),”intends to reside” means that an applicant has a present intent to reside where he or she is living, and intends to remain in the Exchange service area where he or she is seeking coverage. Individuals visiting an Exchange service area for a transitory purpose, for example, to attend to a business matter, obtain medical care, or for personal pleasure, do not have a present intent to reside, and do not meet the residency requirement for Marketplace coverage for the Marketplace service area they are visiting.

        Certain individuals who cannot indicate intent, such as children, can establish residency without showing intent to reside. For more information, see Questions 1 and 4 as well as 45 C.F.R. § 155.305(a)(3) and 42 C.F.R. § 435.403.

        Does an individual’s residence change when he or she leaves an Exchange service area temporarily?

        No. An individual who leaves an Exchange service area temporarily with intent to return to the original Exchange service area continues to be a resident for the purposes of Marketplace coverage during the temporary absence.

        Permanent Move S E P

        How does someone qualify for the Permanent Move S E P to enroll in a QHP or change their enrollment in a QHP?

        To qualify for the Permanent Move S E P under 45 C.F.R. § 155.420(d)(7), a QI or his or her dependent must gain access to new QHPs as a result of a permanent move.

        For the purposes of qualifying for this S E P, a move is considered permanent if a QI (or his or her dependents) moves and meets the Marketplace residency requirement—as described in Questions 1 and 4 with respect to a new location. An individual who moves to a new location temporarily without an intent to reside there or otherwise meeting the Marketplace residency requirement, including for personal pleasure or to obtain medical care, does not qualify for the Permanent Move S E P.

        Similarly, an individual who moves permanently, but does not gain access to new QHPs as a result of the move, would not qualify for the Permanent Move S E P. For example, this may occur if an individual permanently moves within the same apartment building, neighborhood, town, or county, depending on the QHPs offered in the individual’s service area.

        https://www.regtap.info/uploads/library/ENR_FAQ_ResidencyPermanentMove_SEP_5CR_011916.pdf

        So, if you cancel coverage, I don’t see how you would qualify to get coverage when you come back to USA.

        There are travel policies that you can get.

        Here’s our page on coverage out of country. Do NOT take our summary as Gospel. Read your Evidence of Coverage!

        $235/month sounds very low. Must be a bronze plan for a young person. Get quotes here.

        Don’t forget, if you get hurt, sick, ill, kidney disease, cancer, etc. outside the USA, you can always come back and get follow up treatment here. How much does chronic care treatment cost?

        Blue Shield Proofs Required:

        proof required

        Reply
    2. Joe M says:

      I lived overseas last year and this year, I was in the US in January for 3 weeks, left and came back last month and moved back

      Reply
      • Sounds good to me, we just need to have the proofs that you are a new resident in CA. The proofs are listed above and on the Blue Shield simplified guide page 5 # 12. Email or bring to our meeting as many as you can get.

        Reply
    3. Henry says:

      I’m a US Citizen along with my wife and children. We have been living in China the past two years.

      1. How do we get Health Coverage when we come back to the USA?

      2. How do we get a 1095 A or B so we can file our taxes?

      3. What’s this you said on the phone about an exemption?

      Reply
      • 1. When you will come back, if it’s not Open Enrollment, you would qualify for a Special Enrollment CFR 155.420 (d) (7) as it’s a move to a new region. Get FREE no obligation quotes here.

        2. You don’t need a 1095 A, as your exempt from the mandate and not being in the USA – Service Area, you wouldn’t qualify to buy coverage.

        3. File form 8965 to show that you are exempt from the mandate. Links and instructions are on this page.

        Citizens living abroad and certain noncitizens—
        You were:

        A U.S. citizen or a resident alien who was physically present in a foreign country or countries for at least 330 full days during any period of 12 consecutive months;

        A U.S. citizen who was a bona fide resident of a foreign country or countries for an uninterrupted period that includes an entire tax year; Learn More – 8965 Instructions

        Reply
  6. I currently have a Blue Shield plan, not in Covered CA.

    If I change before the 15th or after the 15th, when would the new coverage start?

    • Covered California will allow new enrollees to sign up through the last day of the month for coverage effective on the first day of the next month (e.g., April 30 for a May 1 effective date). Covered CA.com *

      Under Covid 19 you had till the end of the prior month for the 1st of the month.

      Normally it’s the 15th of the prior month for the 1st of the month. Covered CA *

  7. Hi Steve…

    I was offered a new job…and the project has been delayed for up to 4 months.

    We have no income coming into the house with the Covid 19 thing going on…I want to see if we can cancel our current plan and get a policy and subsidies through Covered California until my new project gets going….then we will have health ins through my employer.

    Thank Steve…let me know what you need from us.

    Hope you are staying virus free and healthy.

    Hugs

    Robin

  8. Is there a penalty or even a possibility to change levels on my insurance?

    This $1222 for a Silver HMO, age 60 to 65 is killing me.

  9. Does Employer’s Open Enrollment in June – Allow dependents to have open enrollment into Individual Market?

  10. 1. What is the cost of your health insurance?

    …..A How does it compare to the COBRA offer I uploaded privately to you?

    2. What happens if I get a new job in 20 days.
    …..A What are the payment terms with your company?

    3. Basically how does this insurance work since I am between jobs.

    4. When does your insurance start once I sign up?

    • 1. You can get quotes, pricing, benefits and enroll online 24/7 by clicking here.

      …A I’ll send you a private email on that.

      4. As long as you enroll by the end of the month, it would be effective the first of the month, when you lose MEC Minimum Essential Coverage. Double check as different special enrollment reasons have different deadlines. Most of the time you have to enroll by the 15th to get first of the month. If you want till the end of the month to enroll, we will not be happy campers if you call and ask where your ID cards are on the 1st of the month. Learn More

      3. You buy the plan. When you get new coverage, you cancel the plan.

      2. Then I wasted my time…and you cancel the coverage when your new employer coverage starts.
      ….A You pay the first premium with the application. Then you get billed or automatic payments direct with whatever Insurance Company from # 1 that you choose.

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